NURSING CARE PLAN #1

Name: Patient X
Age: 57-year-old

ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION

OBJECTIVE CUES: Ineffective breathing SHORT TERM INDEPENDENT: SHORT TERM
➢ Dyspnea pattern r/t Wegener’s OUTCOME: ➢ Place patient with proper ➢ A sitting position OUTCOME:
➢ Cough Granulomatosis Within 8 hours of nursing body alignment for permits maximum After 8 hours of nursing
➢ RR – 28 cpm intervention, the client maximum breathing lung excursion and intervention, the client was
➢ O2 – 86% will be able to: pattern. chest expansion. able to:
➢ Demonstrate ➢ Demonstrated
appropriate ➢ Encourage sustained deep ➢ These techniques appropriate coping
coping behaviors. breaths. promote deep behaviors.
➢ Verbalize inspiration, which ➢ Verbalized awareness
awareness of increases oxygenation of causative factors.
causative factors. and prevents ➢ Patient maintains an
➢ Patient maintains atelectasis. effective breathing
an effective pattern, as evidenced
breathing pattern, ➢ Encourage diaphragmatic ➢ This method relaxes by relaxed breathing at
as evidenced by breathing for patients with muscles and increases normal rate and depth
relaxed breathing chronic disease. the patient’s oxygen and absence of
at normal rate and level. dyspnea.
depth and absence
➢ Evaluate the ➢ This improves
of dyspnea. GOAL MET
appropriateness of conscious control of
inspiratory muscle training. respiratory muscles
and inspiratory muscle
strength.

➢ Maintain a clear airway by ➢ This facilitates

encouraging patient to adequate clearance of
mobilize own secretions secretions.
with successful coughing.
 ➢ Stay with the patient ➢ This will reduce the
during acute episodes of patient’s anxiety,
respiratory distress. thereby reducing
oxygen demand.

➢ Encourage small frequent ➢ This prevents

meals. crowding of the
diaphragm.

COLLABORATIVE:
➢ Consult dietitian for dietary ➢ It may cause
modifications. malnutrition which
can affect breathing
pattern. Good nutrition
can strengthen the
functionality of
respiratory muscles.

➢ Refer patient for evaluation ➢ Exercise promotes

of exercise potential and conditioning of
development of respiratory muscles
individualized exercise and patient’s sense of
program. well-being.
 NURSING CARE PLAN #2

Name: Patient X
Age: 57-year-old

ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION

OBJECTIVE CUES: Impaired gas exchange SHORT TERM INDEPENDENT: SHORT TERM
➢ Dyspnea r/t Granulomatosis with OUTCOME: ➢ Position patient with head ➢ Upright position or OUTCOME:
➢ RR – 28 cpm Polyangitis Within 8 hours of nursing of bed elevated, in a semi- semi-Fowler’s After 8 hours of nursing
➢ O2 – 86% intervention, the client Fowler’s position as position allows intervention, the client was
will be able to: tolerated. increased thoracic able to:
➢ Verbalize capacity, full descent ➢ Verbalized
understanding of of diaphragm, and understanding of
causative factors increased lung causative factors and
and appropriate expansion. appropriate
interventions. interventions.
➢ Demonstrate ➢ Regularly check the ➢ Slumped positioning ➢ Demonstrated
improved patient’s position so that he causes the abdomen to improved ventilation.
ventilation. or she does not slump compress the
down in bed. diaphragm and limits GOAL MET
full lung expansion.

➢ Encourage or assist with ➢ Ambulation facilitates

ambulation as per lung expansion,
physician’s order. secretion clearance,
and stimulates deep
breathing.

➢ Encourage slow deep ➢ This technique

breathing using an promotes deep
incentive spirometer as inspiration, which
indicated. increases oxygenation
and prevents
atelectasis.
 ➢ Provide reassurance and
reduce anxiety.
DEPENDENT:
➢ Maintain an oxygen
administration device as
ordered, attempting to
maintain oxygen saturation
at 90% or greater.
➢ Administer humidified
oxygen through
appropriate device
COLLABORATIVE:
➢ Consult dietitian for dietary
modifications.
➢ Anxiety increases
dyspnea, respiratory
rate, and work of
breathing.
➢ Supplemental oxygen
may be required to
maintain PaO2 at an
acceptable level.
➢ A patient with chronic
lung disease may need
a hypoxic drive to
breathe and may
hyperventilate during
oxygen therapy.
➢ It may cause
malnutrition which
can affect breathing
pattern. Good nutrition
can strengthen the
functionality of
respiratory muscles.
 NURSING CARE PLAN #3

Name: Patient X
Age: 57-year-old

ASSESSMENT DIAGNOSIS PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE CUES Deficient Knowledge r/t SHORT TERM INDEPENDENT: SHORT TERM
3 months with the lack of exposure, OUTCOME: ➢ Discuss diagnosis, current ➢ Provides individually OUTCOME:
signs and symptoms unfamiliarity with Within 8 hours of nursing and/or planned therapies, specific information, After 8 hours of nursing
information/resources intervention, the client and expected outcomes. creating a knowledge intervention, the client was
will be able to: base for subsequent able to:
➢ Verbalize learning regarding ➢ Verbalized
understanding of home management. understanding of
ramifications of ramifications of
diagnosis, ➢ Identify signs and ➢ Early detection and diagnosis, prognosis,
prognosis, symptoms requiring timely intervention possible
possible medical evaluations, e.g., may prevent/ complications.
complications. changes in the appearance minimize ➢ Participated in the
of incision, development of complications.
➢ Participate in the learning process.
respiratory difficulty,
learning process.
fever, increased chest pain,
changes in the appearance
of sputum. GOAL MET

➢ Help the patient determine ➢ Weakness and fatigue

activity tolerance and set should decrease as
goals. lung heals and
respiratory function
improves during the
recovery period

➢ Teach the patient how to ➢ Helpful in

perform deep breathing, immediately
 coughing, and ROM maximizing lung
exercises. volume after surgery.

➢ Recommend stopping any ➢ Exhaustion aggravates

activity that causes undue respiratory
fatigue or increased insufficiency.
shortness of breath.

COLLABORATIVE:
➢ Consult dietitian for dietary ➢ It may cause
modifications. malnutrition which
can affect breathing
pattern. Good nutrition
can strengthen the
functionality of
respiratory muscles.